Preburn Emotional and Physical Health

A person’s preburn level of physical and emotional functioning can greatly affect the course of recovery, from stay in the intensive care unit (ICU) to years after discharge. For example, patients with substance abuse disorders, diabetes, chronic obstructive pulmonary disease, and other medical comorbidities have lower survival rates, longer lengths of stay, and fare poorer overall. The available research largely supports the impression that individuals with burns severe enough to warrant hospital care often have preexisting chaos and dysfunction in their lives. In several reviews of the literature, it was found that the incidence of mental illness and personality disorders was higher in burn unit patients than that in the general population. For example, Patterson and colleagues estimated that the presence of premorbid psychiatric disorders ranged between 28% and 75%, higher than that expected in the general population. These disorders include depression, personality disorders, and substance abuse. Another study by Patterson and colleagues found that patients with burn injuries scored higher on premorbid levels of psychological distress, anxiety, depression, and loss of behavioral and emotional control than a national normative sample. These studies also found that individuals with preexisting psychopathologic conditions often cope with hospitalization through previously established, dysfunctional, and often-disruptive patterns. Such dysfunctional coping styles, in turn, had an adverse effect on the hospital course, increasing the length of stay and leading to more serious psychopathologic conditions on discharge. As an example, a burn injury and its subsequent treatment can often exacerbate anxiety in previously anxious patients. Patients with personality disorders can also struggle to cope with their burn injury and have relationship patterns with staff, which are dysfunctional and cause great difficulty for the staff. Mental health professionals need to be an integral part of the team, should help to educate burn-team members about preexisting conditions, and should understand that a person with a burn injury will not be cured of their personality disorder, mental illness, or depression, while in the burn unit.

Injury Characteristics

Researchers have begun to focus on potential variables from acute hospitalization that may have a long-term effect on adjustment. Total burn surface area (TBSA), length of hospitalization, and days spent in the ICU or on a ventilator have been used as indicators of the severity of burn injuries. Research on the relation between these variables and outcomes has been equivocal. Patterson and colleagues cautioned against using TBSA as the sole predictor of emotional outcome, citing studies that have shown significant emotional distress in persons with relatively small burns and little to no distress in persons with large burns. High inpatient pain levels have also been found to lead to long-term distress. The severity of pain that patients report in the hospital supersedes both the size of their burns and the length of hospitalization as a predictor of long-term outcome at 6 months, 1 year, and 2 years postdischarge. Location of the burn has been found to predict adjustment, with those persons with burns on their face or hands showing more emotional distress than those with more hidden burns.

Coping

In the general literature on coping, Lazarus and Folkman proposed a comprehensive model of stress and coping based on the notion that a person’s appraisal of the demands and consequences of a situation and the amount of control they perceive they have over the situation lead to the selection of a particular coping strategy. Several organizing terms have been used to categorize coping styles. The extent to which a coping strategy involves approaching a particular stressor, rather than avoiding the stressor, is a widely used classification. For instance, active strategies such as problem solving, information seeking, and social support seeking can be construed as approach-oriented coping and strategies that involve disengagement, denial, or distraction can be viewed as avoidance-oriented efforts. Neither approach-oriented nor avoidance-oriented coping behaviors are inherently adaptive or maladaptive; coping effectiveness is better determined by the characteristics of the individual and the situation. However, reviews of the literature on coping with chronic illness have suggested that approach-oriented coping styles are more favorable to physical and emotional health outcomes in medical populations.

Some research has suggested that the selection of a specific coping strategy depends on the individual’s appraisal of the amount of control they have over the situation. For example, if a person appraises the situation as being more controllable, then they use a strategy in which they attempt to actively solve the problem or mobilize resources; if they appraise low levels of control, then they are likely to use strategies in which they distract their attention away from the stressor. Little research has attempted to characterize the adaptiveness of specific coping strategies in burn patients over time. It is also unknown whether a person can be taught a specific coping style, especially when under considerable stress, such as recovering from a burn injury.

Emotional Distress

The first year or two following a burn injury appears to be a time of substantial distress. Clearly, mood disorders and anxiety disorders are the most common symptoms of distress; however, patients may also experience myriad other problems, including sleep disturbance, body image concerns, and sexual problems. All of these symptoms potentially contribute to decreased quality of life.

Posttraumatic Stress Disorder

The reported frequency of acute stress disorder (ASD) following a burn injury ranges from 11% to 32%. The frequency of posttraumatic stress disorder (PTSD) 3 to 6 months after a burn injury is approximately 23% to 33%, whereas the same ranges from 15% to 45% 1 year after a burn injury. In contrast, community-based studies show that the lifetime prevalence of persons with PTSD is 1% to 14%. The large variability in reported rates of diagnosed ASD/PTSD is likely to have been caused by differences in measurement strategies and measurement time points. However, most researchers and clinicians agree that even if patients do not meet a formal diagnosis of ASD or PTSD, most burn patients have at least some of the symptoms of this disorder (eg, nightmares, intrusive thoughts, hypervigilance, avoidance) that negatively affect their quality of life. Preexisting anxiety or depressive disorders are associated with an increased risk of developing PTSD. Further, the baseline symptoms of ASD and at 1 month after discharge predict the presence of PTSD at 1 year, suggesting that symptoms do not decrease over time if left untreated. In addition, burn patients with a comorbid diagnosis of PTSD are frequent users of medical services. Injury-related characteristics in burn patients, such as TBSA and the location of the injury, have repeatedly failed to predict such trauma. In contrast, issues such as the patient’s mental health history, social support, and coping style hold promise as predictive factors. The authors recommend a screening tool, such as the Post-Traumatic Stress Disorder Symptom Checklist–Civilian Version (PCL-C), to identify patients with symptoms of PTSD.

Depression

Research that has attempted to identify rates of depressive disorders following burn injury has been fraught with challenges. In their comprehensive review, Thombs and colleagues found that most studies are from single centers, with small sample sizes and poor rates of recruitment and retention. In addition, the multiple approaches and measures used have led to a wide variation in reported rates of depressive symptoms and diagnosable disorders. For example, the range of reported symptoms in the first year after a burn injury is from 2% to 22%, and the prevalence rate after 1 year is 3% to 54%. The prevalence rates of depression are much lower when a structured interview rather than a standardized measure is used. But even when standardized measures are used, the rates vary widely. The most common standardized measures are the Hospital Anxiety and Depression Scale (HADS)—depression subscale and the Beck Depression Inventory (BDI). The HADS does not include questions about somatic symptoms but the BDI does. It is often difficult to differentiate between the symptoms that can be attributed to the medical disorder and the somatic symptoms of depression, which could account for the higher reported rates of depression, when using the BDI rather than the HADS. Whether a measure of depression that is specific to those with burn injuries needs to be designed and validated is still under debate. The 9-item Patient Health Questionnaire is a widely used screening tool in primary care and other medical specialty clinics and may prove to be useful in the burn setting.

Several studies have also found that depression rates tend to be stable from discharge to at least the first year following a burn injury. Although it is commonly assumed that these rates decrease after the first year, no longitudinal studies have reported depression rates more than 1 year postinjury. Thombs and colleagues found 7 studies that reported on risk factors for depression following burn injury. As mentioned earlier, many of the identified risk factors encompass premorbid functioning, such as employment status, medical illness, and prior depression. Patients with depressive symptoms in the year before the burn injury were 5 times more likely to be diagnosed with a mood disorder at hospital discharge. Other risk factors include the female gender and visible burns. Although research in this area has been fraught with methodological problems that make it difficult to pin down actual rates of depressive disorders, the authors recommend a brief screen for depressive symptoms during inpatient hospitalization, discharge, and follow-up clinic visits. Referrals to mental health professionals can be made for more in-depth assessments, if warranted by the responses on the screening tool.

Pain

It is important to discuss pain when reviewing the outcomes of burn injuries. Perry and Heidrich reported that burn patients typically report their acute pain as being severe or excruciating, despite receiving opioid analgesics. However, it is important to realize that burn pain varies greatly from patient to patient, shows substantial fluctuation over time, and can be unpredictable because of the complex interaction of physiologic, psychosocial, and premorbid behavior issues. Burn pain that is reported after the initial injury is not reliably correlated with the size or depth of a burn. A patient with a superficial (second degree) burn may show substantially more pain than one with a full-thickness (third degree) burn, because of both physical (eg, location and mechanism of the injury, individual differences in pain threshold and tolerance, response to analgesics) and psychological factors (eg, previous pain experiences, anxiety, depression). Indirect assessments of pain using measures of sympathetic nervous system activation (eg, hypertension, tachycardia, tachypnea) that may be of value in other acute pain settings are notoriously inaccurate in the patient with burn injuries because of the complex metabolic response. As a result, it is critical to realize that predicting the amount of pain or suffering that a patient will experience based on the nature of or the physiologic response to the burn injury is not possible, and furthermore, the patient’s pain experience can change dramatically during the course of both inpatient and outpatient care. It is also important to note that pain can continue well after wound healing.

Because of this unpredictability, a more useful paradigm for describing acute burn pain is based on the clinical settings in which it commonly occurs. This approach is also useful because analgesic treatment decisions can also be based on such a classification. Thus, burn pain is generally classified into 5 clinical settings :

• 1.
  

  Background: pain that is present while the patient is at rest, results from the thermal tissue injury itself, and is typically of low-moderate intensity and long duration (until the burn wound is healed)

  
  
• 2.
  

  Procedural: a brief but intense pain generated by wound care (eg, debridement, dressing change) or rehabilitation activities (physical and occupational therapies)

  
  
• 3.
  

  Breakthrough: an unexpected spiking of pain levels that occurs when analgesic efforts are exceeded, either at rest or during procedures

  
  
• 4.
  

  Postoperative: a predictable and temporary (2–5 days) increase in pain complaints following burn excision and grafting, in large part because of the creation of new wounds in the processes of skin graft harvesting and autografting

  
  
• 5.
  

  Chronic: pain that lasts longer than 6 months or remains after all burn wounds and skin graft donor sites have healed, and is thus a challenge primarily in the outpatient setting.

Chronic burn pain warrants further discussion because it has the greatest effect on the rehabilitation phase of recovery. The mechanisms and treatment of chronic burn pain are inadequately studied and poorly understood. Although most acute burn pain results from tissue damage, it is important to be aware that pain from nerve damage may also be present, particularly in severe injuries associated with extremity amputations, and represent an anatomic source for chronic burn pain complaints. Because there are identifiable sensory changes in patients with burn injuries, it is unclear whether these patients’ pain should be defined as chronic pain or simply as an ongoing form of acute or neuropathic pain. Regardless of the label used to classify postburn injury chronic pain, ongoing pain has the potential to have a significant negative effect on the quality of life of burn patients.

Malenfant and colleagues found evidence for changes in the central nervous system that could maintain pain for years after a burn wound has healed. They found that significant sensory losses and sensory changes were found not only in burn sites but also in noninjured areas. Tactile sensibility deficits were significantly associated with the presence of painful sensations. This was greatest in deep burn injuries that required skin grafting.

Choiniere and colleagues interviewed 104 burn patients who were in their first to seventh year post–burn injury. The mean time since burn injury was 37 months, and the mean TBSA was 19%. Surprisingly, 35% reported ongoing pain. Of those reporting pain, 75% reported interference interfered with work, 56% with sleep, and 67% with social functioning. In a sample of 236 burn patients 1 to 9 years post–burn injury with a mean time since injury of 47 months and a mean TBSA of 20%, Malenfant and colleagues found a similar rate of patients with ongoing pain (36%). Work interference was reported by 67% of those with pain, 36% reported sleep difficulties, and 47% reported disturbance in social activities. Schneider and colleagues reviewed the natural history of neuropathy-like pain after a burn injury. Over a 2-year period, they found 72 patients in their outpatient clinic who described symptoms consistent with neuropathic pain. The average pain rating was 7 of 10, and the pain persisted for more than 1 year after the injury. In this study, gabapentin and steroid injections were used to treat the pain in about one-third of the cases. Other interventions included rest, massage, use of pressure garments, and elevation.

Finally, Dauber and colleagues mailed a questionnaire to members of a burn survivor support group, and of the 358 respondents, 52% reported ongoing pain, 66% said that it interfered with their rehabilitation, and 55% said the pain interfered with their daily lives. Respondents in this study also reported that thoughts of the accident and depression made their pain worse. In these studies, TBSA and skin grafting were the only predictors of chronic pain. Most respondents had not tried relaxation, imagery, or hypnosis. It is important to note that the average length of time since the burn injury in 2 of these studies was 3 to 4 years. This period is well past the 1-year time frame that medical professionals think it takes for burn injuries to be completely healed.

To provide comprehensive and consistent analgesic care for burn patients, many burn centers advocate a structured approach to burn analgesia that incorporates both pharmacologic and nonpharmacologic therapies and targets the specific clinical pain settings unique to the burn patient and yet can be individualized to meet specific patient needs and institutional capabilities. Such structured protocols help to avoid the undertreatment of burn pain that has been observed when burn unit staff members fail to medicate patients adequately, despite education regarding the low risk for addictive and other side effects. There is currently no evidence to support that opioid addiction occurs more commonly in burn patients without premorbid substance abuse issues than in other patient populations requiring such analgesics for acute pain. In fact, poorly treated pain in the acute setting can have long-term adverse effects. Further, neuropathic pain that goes untreated in the outpatient setting can inhibit recovery, particularly if high pain levels impair sleep and inhibit a patient’s ability to participate in therapies or return to work. A discussion of specific pharmacologic treatments and protocols used to treat burn pain is beyond the scope of this article and can be found elsewhere.

Distraction

Various forms of distraction techniques are available. Common distraction techniques used with children include bubble blowing, singing songs, reading a story, and counting. Adults may require a bit more creativity but can engage in an enjoyable conversation, listen to music, play a video game, or immerse themselves in interactive virtual reality (VR; see later discussion) during the procedure.

Virtual Reality

Immersive VR is a technology that isolates patients from the outside world, including any threatening stimuli associated with health care. Immersive VR uses a helmet that blocks the user’s view of the real world and gives the patient the illusion of going into the 3-dimensional computer-generated environment, a condition known as “presence.” This quality makes immersive VR particularly effective in capturing participants’ attention. In the burn-pain setting, the authors used a virtual environment called SnowWorld, where patients float through an icy canyon and are able to direct snowballs at virtual snowmen and igloos as they appear. The image of snow was specifically chosen because its connotation of cooling is in direct contrast to the hot sensations often associated with burn pain.

The theory behind the effectiveness of VR is that attention involves the limited selection of relevant information from a variety of inputs or tasks, and each human has a finite amount of attention available. The strength of the illusion, or presence, is thought to reflect the amount of attention drawn into the virtual world. Because VR is designed to be a highly attention-grabbing experience, it reduces the amount of conscious attention available to process pain. Less attention to pain not only results in a reduction in perceived pain intensity and unpleasantness but also reduces the time patients spend thinking about their pain. VR has been shown to be effective in reducing pain in several clinical studies using it for pain distraction. VR technology can also be used to administer hypnotic analgesia and is particularly effective with patients who have difficulty imagining a scene.

Imagery

Imagery is simply creating or recreating an image in one’s mind, presumably one that patients find pleasant and engaging. Types of imagery can be infinite and depend on the desired goals. For example, many people use healing imagery to promote this result when overcoming disease or injury. They might imagine processes, such as increased blood flow to the injured area to carry away damaged tissue and rebuild new tissue or decrease inflammation in the injured area. Although healing imagery can be an effective means of helping the burn patient feel more in control of their situation, it forces a person to focus on the injury and is therefore not a distraction technique when used in this way. In contrast, relaxation imagery tends to work best for pain control and is another form of distraction. Before a painful procedure, the clinician often talks to patients about safe or favorite places to which they can go. It can be a place where they have been before (eg, a favorite vacation spot) or simply a place that they imagine to be relaxing and safe. The clinician then collects as many details as possible about the place, such as the colors, the sounds, the smells, and objects in a place, and makes the patients practice the imagery; before the procedure, patients are encouraged to relax through deep breathing, closing their eyes, and imagining their favorite places. The patients are simply cued with the details that they have provided before beginning relaxation. Next, the patients are encouraged to imagine the place during their subsequent therapy. Children often enjoy more active forms of imagery that relate to fantasy, such as a magic carpet ride. There are also numerous imagery scripts that have been published and can be used when a person is unable to think of a safe or favorite place. These scripts usually entail a person flying or floating on a cloud through beautiful places. It is important to note that a patient should be asked about any fears, such as fear of heights, flying, or water, so that use of these images does not actually create more anxiety.

Hypnotic Analgesia

Although hypnosis involves much more than just avoidance or distraction, the end result is often similar in that this technique takes a person’s focus off the painful procedure they are undergoing. Hypnosis is an altered state of consciousness characterized by an increased receptivity to suggestion, the ability to alter perceptions and sensations, and an increased capacity for dissociation. It is believed that the dramatic shift in consciousness that occurs with hypnosis is the cornerstone of an individual’s ability to change the awareness of pain. Hypnosis involves several stages, including building clinician-patient rapport, enhancing relaxation through deep breathing, deepening the hypnotic state and narrowing the patient’s attention, providing posthypnotic suggestions, and alerting. Posthypnotic suggestions permit hypnosis at any time before a painful procedure, thus eliminating the need for the clinician’s presence during the procedure. The authors use a rapid induction analgesia format described by Patterson and originally published by Barber, but there are numerous scripts for hypnotic analgesia that can be used directly or with improvisation. However, the technique should only be used by trained clinicians who can assess the risks and benefits of this powerful technique.

Deep Breathing

Deep breathing, also known as diaphragmatic breathing, is one of the least time-consuming techniques and the easiest technique for adults and children to learn. When a person becomes anxious and/or experiences pain, breathing becomes shallow and irregular because of the increased muscle tension in the chest wall. This type of shallow breathing, known as thoracic breathing, leads to an increase in muscle tension and subsequent heightened pain. Teaching patients to have an awareness of this cycle and some deep breathing techniques that allow them to break it lead to a relaxation response that can alleviate some pain. Bubble blowing and blowing on a pinwheel are helpful tools to use with children to encourage deep breathing. Adults can be taught to place a hand on the stomach and to take a deep enough breath so that it passes through the chest and fills the stomach. The hand should rise and fall with the stomach. The exhalation is the most important part of deep breathing and should not be rushed. Diaphragmatic breathing is central to all forms of relaxation and is simple and time efficient.

Progressive Muscle Relaxation

When patients are experiencing stress, such as pain, they tend to use muscles inefficiently, resulting in muscle bracing that can lead to an increase in pain. Progressive muscle relaxation is a technique developed by a physician, Edmund Jacobson, after observing increased muscle tension in hospitalized patients and discovering that more-tense patients took longer to recuperate and had poorer outcomes. He taught patients to systematically focus on a muscle group, tense and relax it, and then progress to a different group. This progression usually starts with the distal muscle groups and moves to the proximal ones until total body relaxation is achieved. Most patients are able to learn this technique with practice, using a prewritten or individually tailored script or independently using commercial audiotapes. If a person is unable to actively tense a muscle group because of pain or injury, he/she can still imagine each muscle becoming progressively warm, heavy, and relaxed, a process known as autogenic training. The patients repeat each statement to themselves as they hear it in on a tape (eg, “My right hand is heavy, my right hand is relaxed, my right hand is becoming warm…”).

Quota System

The quota system is an operant technique often used by burn care providers to promote a sense of mastery among patients undergoing painful wound care procedures and difficult physical therapies. Caregivers are encouraged to pace their procedural demands in a manner that is consistent with the individual’s level of tolerance by taking baseline measurements for each task that needs to be performed and gradually (10% per day) increasing the demands of each task. Rest is used as the reinforcement for successfully reaching a quota or in other words, meeting a predetermined task. Goals for each task are determined based on what was done the previous day, and patients are expected to work until the goal is accomplished rather than work until they feel pain or fatigue. This technique puts more control in the hands of the patient, preventing a syndrome of learned helplessness that can often develop because of painful therapies. It also avoids reinforcing pain behaviors. The quota system is based on the notion that although physical therapies after a burn injury are painful, this pain itself is not damaging and does not negatively affect outcome.

Positive Reinforcement

Another operating principle that is often successful with patients with burn injuries, particularly children, is positive reinforcement. There is no intrinsically rewarding aspect of a burn injury or burn recovery. In fact, children often see the treatment for a burn injury as a punishment. Therefore, children need to be rewarded for participation in the recovery process and for displaying appropriate behavior. For example, it is common in a rehabilitation unit to find a sticker board and prize box in each child’s room. Behavioral expectations are established in advance and define the responsibilities the child has for that day, including wound care, physical and occupational therapy, eating meals, and so forth. They receive rewards (stickers) for each responsibility that is accomplished. Once they have a set number of stickers, they are able to pick a bigger prize from the prize box, which is known as establishing a token economy. Other creative means of positive reinforcement can also be effective, such as reading stories, watching movies or television, or offering adult attention through playing a game or reading a story. When children are frequently reinforced for good behavior or after completing a therapeutic goal, it lessens the need for punishment for bad behavior and makes the therapy more tolerable.

Cognitive Restructuring

Cognitive restructuring is frequently used as a coping technique for patients with chronic pain. There are reports in the literature of the use of this technique for coping with various type of pain, including pain from dental and surgical procedures. A handful of studies have analyzed this approach for burn pain. Catastrophizing has been found to have the strongest link between thoughts and pain. This distorted thinking style exaggerates any sensation of pain or a setback and becomes a point of perseveration for the patient. For example, a minor setback in therapy following a planned surgery (such as a contracture release), a wound infection, or simple fatigue can turn into thoughts such as “I can’t take this anymore; I have to start all over again; I will never recover.”

The first step in cognitive restructuring is to identify and stop negative catastrophizing thoughts, such as “this is really going to hurt” and “I can’t handle this pain,” that only lead to an increase in anxiety and a subsequent increase in pain. Patients can learn to recognize these negative thoughts and stop them, perhaps by picturing a stop sign or red light in their mind. They can also distract themselves by turning their attention to another topic. Children as young as 7 years have been taught to use this technique successfully.

Ideally, the authors want patients to transform their catastrophic thoughts into positive statements. This is known as reappraisal or reframing. For example, they may change the negative thought in the previous example to “I have been through this wound care procedure before and it did not hurt as much as I thought it would” or “I have a very high pain tolerance and can cope with whatever will happen.” Patients may also benefit from being taught the difference between hurt and harm, when interpreting their pain sensations. Specifically, an increase in pain is often a good sign with respect to burn wound healing. As discussed earlier, deep (third degree) burns often destroy nerve endings and limit the capacity for nociception. In deep burns that begin to heal or in more shallow burns, skin buds develop, which are highly innervated and sensitive to pain and temperature. Explaining this healing process to patients can help them to understand the nature of their pain and to reframe negative thoughts into reassuring positive ones.

Participation

Allowing patients who have more of an approach coping style to participate in their own burn care and recovery is one of the simplest and most effective ways to increase their sense of control and reduce anxiety. The authors often use the technique of “forced choice” for children to create more of a sense of control over their environment, without overwhelming them with choices. When a child needs to accomplish an unpleasant task, parents and caregivers can create a situation whereby the child is given 2 choices in how to proceed with the task. For example, a child who is having difficulty in physical therapy may be given the choice of having the therapy before lunch or after lunch, or picking the exercise that they start with. This method is likely to fail if more than 2 choices are given or if a child is presented with an option that caregivers or parents have no intention of allowing. Setting rehabilitation goals is also an area where patients, particularly adults, should be allowed to participate. Patients will be more motivated to work to achieve the rehabilitation goals if they have helped to define them. Goals are very individual, and each patient will have different goals depending on their priorities and their level of desired independence. For example, a mother of young children may have a goal of regaining enough strength and function to lift her baby, whereas a construction worker may have a goal of being able to grip a hammer or other tools.

Recently, there have been several rigorous systematic reviews of studies that have focused on both pediatric and adult nonpharmacologic pain management strategies. Hanson and colleagues conducted a systematic review of nonpharmacologic interventions for acute procedural pain in pediatric patients with burn injuries. Using the systematic review methods of the US Preventive Services Task Force, they found 12 articles that met the study criteria, and 7 of the 12 articles were rated as fair or good. They categorized these 12 articles into child-mediated, parent-mediated, and health care provider–mediated interventions. Of the child-mediated interventions, both VR distraction and stress management showed promising results. Of the health care provider interventions, massage therapy and optimizing patient control during wound care were effective in relieving wound care pain when compared with a control group. Parent-mediated interventions were not found to be effective, and in fact, one study showed an increase in distress in children when parents were present. Although the study designs in these interventions were rated as poor, the findings are consistent with those reported by clinicians, in that parental presence during painful procedures can either help a child or hurt a child, depending on the parents’ affect and ability to soothe their child. This is a difficult intervention to study but one that deserves more attention in this era of family-centered care and emphasis on increased parental involvement in a child’s care. It would be a tremendous benefit to the field if the variables that are necessary to facilitate a positive parental presence and the variables that serve as barriers to the success of this treatment could be determined. Hanson and colleagues acknowledged that it was very difficult to conduct randomized controlled trials with adequate sample sizes in this population, but there is need to find empirical support for the techniques that are chosen.

de Jong and colleagues also conducted a systematic review of the literature for nonpharmacologic interventions for acute burn pain in adults. They found that hypnosis was the most frequently studied intervention and that most studies on hypnosis showed a beneficial effect when compared with a control group. They concluded that hypnosis seems to have a strong effect on the affective component of pain. Their review also showed beneficial effects through distraction relaxation and found that any technique that enhances a patient’s control over the situation is beneficial.

The investigators of these systematic reviews have provided directions for future research that would advance knowledge of the effectiveness of nonpharmacologic interventions. These suggestions included the need for large sample sizes, documentation regarding study response rates and randomization methods, experimental control for premorbid psychosocial variables, details on instructions given to patients, cost outcomes, and assurance of treatment integrity/adherence.